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Ultrasonography of the Ankle: a Step-By-Step Guide

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Ultrasonography of the Ankle: a Step-By-Step Guide Ultrasonography of the Ankle: a step-by-step guide Poster No.: C-1806 Congress: ECR 2017 Type: Educational Exhibit Authors: M. Cruz1, C. Ferreira1, P. G. Oliveira1, C. Ruivo1, F. Cruz1, F. Caseiro Alves2; 1Coimbra/PT, 2Coimbra, Coimbra/PT Keywords: Motility, Education and training, Athletic injuries, Technical aspects, Education, Diagnostic procedure, Ultrasound, Musculoskeletal joint, Extremities, Anatomy DOI: 10.1594/ecr2017/C-1806 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to third- party sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myESR.org Page 1 of 39 Learning objectives The purpose of this article is to review the normal ultrasound anatomy of the ankle joint and propose a checklist-based evaluation protocol. Didactic illustrations and iconographic documentation are used for the scanning technique, probe positioning and normal findings. Background Being the most frequently injured major joint amongst the general population, Imaging plays a crucial role in the evaluation of the ankle. The superficial location of most structures and the possibility of performing dynamic maneuvers during the exam means that ultrasound plays an important role in the management of patients with painful conditions of the ankle. Findings and procedure details The ankle can be subdivided into four major compartments: anterior, lateral, medial and posterior. Each of these anatomic regions include key structures that are essential for the normal function of the ankle joint and that can be assessed by ultrasonography. Anterior ankle Key structures: • Anterior tendons (extensor tendons and tibialis anterior) • Deep peroneal nerve and anterior tibial vessels • Anterior joint (tibiotalar) recess Starting position: Page 2 of 39 To examine the anterior ankle, the patient should either be seated on the table with the knee flexed at 90° and the plantar surface of the foot flat on the table [Fig. 1] or lain supine with the foot free, allowing manipulation by the examiner. Fig. 1: Starting position to evaluate the anterior ankle. Page 3 of 39 References: - Coimbra/PT Anterior tendons Place the probe on an axial plane over the dorsum of the ankle [Fig. 2] to examine the tibialis anterior, extensor hallucis longus and extensor digitorum longus (medial to lateral). These tendons must be followed from their myotendinous junction to their distal insertion onto the first cuneiform (tibialis anterior) and fingers (extensor tendons). On this plane, the extensor retinaculum can be identified superficially and the neurovascular bundle (which includes the deep peroneal nerve and anterior tibial vessels) can be assessed deeply, between the extensor tendons. Long axis scans can be useful when assessing distal bone insertions. Fig. 2: A) Probe positioning for transverse scanning of the anterior ankle. B) Transverse ultrasound scan of tibialis anterior tendon (ta), extensor hallucis longus tendon (ehl), extensor digitorum longus tendon (edl) and the neurovascular bundle which includes the deep peroneal nerve and anterior tibial vessels (arrowhead). References: - Coimbra/PT Anterior joint (tibiotalar) recess The probe should be placed on a mid longitudinal plane over the dorsum of the ankle, between the extensor tendons [Fig. 3]. The recess has a concave shape and contains the normal fat pad when not distended by fluid. Talus' cartilage may also be assessed Page 4 of 39 on this plane. Note that a small quantity of fluid is usually seen in its anterior part, which is a physiological finding. Fig. 3: A) Probe positioning for scanning the anterior joint recess. B) Longitudinal ultrasound scan of the anterior joint recess (arrowheads). Note the small amount of physiological fluid (asterisk) in its anterior part, which is a common finding. References: - Coimbra/PT Lateral ankle Key structures: • Anterior tibiofibular ligament • Anterior talofibular ligament • Calcaneofibular ligament • Peroneal tendons Starting position: To examine the lateral ankle, the patient should either be seated on the table with the knee flexed at 90° and the foot slightly internally rotated [Fig. 4] or lain supine with the foot free, allowing manipulation by the examiner. Page 5 of 39 Fig. 4: Starting position to evaluate the lateral ankle. References: - Coimbra/PT Then, the tip of the lateral malleolus is an useful landmark to evaluate the lateral ligaments: one edge of the probe should be held over it, while the other edge is placed anteriorly (anterior talofibular ligament), rotated cranially (anterior tibiofibular ligament) or rotated caudally with dorsal flexion of the foot (calcaneofibular ligament) [Fig. 5]. Page 6 of 39 Fig. 5: Animated image showing probe and foot positioning to evaluate the anterior talofibular, anterior tibiofibular and calcaneofibular ligaments. Note the lateral malleolus as an useful landmark. References: - Coimbra/PT Anterior talofibular ligament Place the probe parallel to the sole of the foot, with one edge over the tip of the lateral malleolus and the other anteriorly to examine the anterior talofibular ligament [Fig. 6]. Page 7 of 39 Fig. 6: A) Probe positioning for scanning the anterior talofibular ligament. B) Longitudinal ultrasound scan of the anterior talofibular ligament (arrowheads). References: - Coimbra/PT The functionality of this ligament can be tested by using the anterior drawer test [Fig. 7], which consists of pulling the foot anteriorly with plantar flexion and internal rotation and may help differentiate partial from full thickness tears. Fig. 7: Photograph showing how to perform the anterior drawer test (stress position to evaluate the anterior talofibular ligament). References: - Coimbra/PT Anterior tibiofibular ligament Page 8 of 39 From the position used to evaluate the anterior talofibular ligament, rotate the anterior edge of the probe cranially to image the anterior tibiofibular ligament [Fig. 8]. Fig. 8: A) Probe positioning for scanning the anterior tibiofibular ligament. B) Longitudinal ultrasound scan of the anterior tibiofibular ligament (arrowheads). References: - Coimbra/PT Calcaneofibular ligament From the position used to evaluate the anterior talofibular ligament, rotate the anterior edge of the probe caudally until a coronal plane is reached (with a slight posterior tilt of the distal edge) in order to image the calcaneofibular ligament [Fig. 9]. As it exhibits a concave course, the foot should be flexed dorsally, thus straightening the ligament and allowing optimal visibility. Page 9 of 39 Fig. 9: A) Probe positioning for scanning the calcaneofibular ligament. B) Longitudinal ultrasound scan of the calcaneofibular ligament (arrowheads). References: - Coimbra/PT When the calcaneofibular ligament is intact, dorsiflexion displaces the peroneal tendons superficially. Absence of this displacement during forced dorsiflexion is an indirect sign of calcaneofibular ligament tear. (Note: The posterior inferior tibiofibular ligament, that extends transversely from the posterior aspect of the lateral malleolus to the posterior tubercle of the tibial shaft, is not usually assessed during ultrasound evaluation. The main reasons are its very low visibility and the fact that it is rarely involved in ankle sprains.) Peroneal tendons The peroneal tendons should be assessed on sequenced short-axis planes, moving the probe along their course, which is cranio-caudal as they run posteriorly to the lateral malleolus but becomes progressively horizontal as they turn around the lateral malleolus' distal tip [Fig. 10]. Page 10 of 39 Fig. 10: Probe positions for assessing sequenced short-axis scans along the course of the peroneal tendons. References: - Coimbra/PT The peroneus brevis tendon has a typical crescent appearance and is located deep to the oval shaped peroneus longus tendon [Figs. 11-13]. They should be followed from their myotendinous junction to the insertion of peroneus brevis onto the base of the fifth metatarsal bone. Long axis scans can be useful when assessing distal bone insertions. The superior and inferior peroneal retinaculum should also be examined. Subluxation of the peroneals can be assessed by performing dorsiflexion and eversion while scanning the superior peroneal retinaculum (an axial plane at the level of the lateral malleolus). Page 11 of 39 Fig. 11: A) Probe positioning for scanning the peroneal tendons at their course proximal to the lateral malleolus. B) Transverse ultrasound scan of the peroneus longus tendon (pl) and peroneus
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